Healthcare Provider Details

I. General information

NPI: 1548430788
Provider Name (Legal Business Name): GORGEOS SMILE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2008
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

871 E TREMONT AVE
BRONX NY
10460-4207
US

IV. Provider business mailing address

871 E TREMONT AVE
BRONX NY
10460-4207
US

V. Phone/Fax

Practice location:
  • Phone: 718-299-5900
  • Fax:
Mailing address:
  • Phone: 718-299-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number053195
License Number StateNY

VIII. Authorized Official

Name: KRISTINA GABRILYANTS
Title or Position: DENTIST
Credential: DDS
Phone: 718-299-5900